Healthcare Provider Details

I. General information

NPI: 1538486402
Provider Name (Legal Business Name): FREMONT COUNSELING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/30/2010
Last Update Date: 04/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 MAJOR AVE
RIVERTON WY
82501-2342
US

IV. Provider business mailing address

1110 MAJOR AVE
RIVERTON WY
82501-2342
US

V. Phone/Fax

Practice location:
  • Phone: 307-856-6587
  • Fax:
Mailing address:
  • Phone: 307-856-6587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberLPC-1147
License Number StateWY

VIII. Authorized Official

Name: MS. BARBARA RAE CONNER
Title or Position: SUBSTANCE ABUSE CLINICIAN
Credential: LPC
Phone: 307-856-6587